Van Diest Medical Center

All Charges

Charge

Type

Setting

Price

SHORT 5TH MET HOOK PLATE LEFT

Facility

$2,574.00

Service Code	HCPCS C1713
Hospital Charge Code	8967552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,158.30
Max. Negotiated Rate	$2,316.60
Rate for Payer: Aetna of IA Commercial	$2,316.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,316.60
Rate for Payer: Aetna of IA Medicare	$1,467.18
Rate for Payer: Amerigroup Medicaid	$1,484.68
Rate for Payer: Amerigroup Medicare	$1,169.88
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,930.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$1,158.30
Rate for Payer: Iowa Total Care Managed Medicaid	$1,470.27
Rate for Payer: Medical Associates Commercial	$1,930.50
Rate for Payer: Medical Associates Managed Medicare	$1,158.30
Rate for Payer: Midlands Choice Commercial	$1,801.80
Rate for Payer: Molina Healthcare Managed Medicaid	$1,491.89
Rate for Payer: Partners Health Alliance Commercial	$1,332.04
Rate for Payer: United Healthcare Commercial	$2,316.60
Rate for Payer: United Healthcare Managed Medicare	$1,518.66

SHORT 5TH MET HOOK PLATE LEFT

Facility

$2,574.00

Service Code	HCPCS C1713
Hospital Charge Code	8967552
Hospital Revenue Code	278
Min. Negotiated Rate	$1,801.80
Max. Negotiated Rate	$2,316.60
Rate for Payer: Aetna of IA Commercial	$2,316.60
Rate for Payer: Aetna of IA Medical Rental Products	$2,316.60
Rate for Payer: Cash Price	$2,059.20
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,930.50
Rate for Payer: Medical Associates Commercial	$1,930.50
Rate for Payer: Midlands Choice Commercial	$1,801.80
Rate for Payer: United Healthcare Commercial	$2,316.60

SHORT CONDYLAR PLATE

Facility

$171.00

Service Code	HCPCS C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$76.95
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Aetna of IA Medicare	$97.47
Rate for Payer: Amerigroup Medicaid	$98.63
Rate for Payer: Amerigroup Medicare	$77.72
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$76.95
Rate for Payer: Iowa Total Care Managed Medicaid	$97.68
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Medical Associates Managed Medicare	$76.95
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: Molina Healthcare Managed Medicaid	$99.11
Rate for Payer: Partners Health Alliance Commercial	$88.49
Rate for Payer: United Healthcare Commercial	$153.90
Rate for Payer: United Healthcare Managed Medicare	$100.89

SHORT CONDYLAR PLATE

Facility

$171.00

Service Code	HCPCS C1713
Hospital Charge Code	8814828
Hospital Revenue Code	278
Min. Negotiated Rate	$119.70
Max. Negotiated Rate	$153.90
Rate for Payer: Aetna of IA Commercial	$153.90
Rate for Payer: Aetna of IA Medical Rental Products	$153.90
Rate for Payer: Cash Price	$136.80
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$128.25
Rate for Payer: Medical Associates Commercial	$128.25
Rate for Payer: Midlands Choice Commercial	$119.70
Rate for Payer: United Healthcare Commercial	$153.90

SHORTENING OF TENDON, EXTENSOR, HAND OR FINGER, EACH TENDON

Facility

$3,486.38

Service Code	CPT 26477
Hospital Revenue Code	360
Min. Negotiated Rate	$3,164.98
Max. Negotiated Rate	$3,486.38
Rate for Payer: Wellmark IA HMO WHPI	$3,164.98
Rate for Payer: Wellmark IA PPO	$3,486.38

SHORT LESSER METZ-PLATE

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$720.90
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Aetna of IA Medicare	$913.14
Rate for Payer: Amerigroup Medicaid	$924.03
Rate for Payer: Amerigroup Medicare	$728.11
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$720.90
Rate for Payer: Iowa Total Care Managed Medicaid	$915.06
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Medical Associates Managed Medicare	$720.90
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: Molina Healthcare Managed Medicaid	$928.52
Rate for Payer: Partners Health Alliance Commercial	$829.04
Rate for Payer: United Healthcare Commercial	$1,441.80
Rate for Payer: United Healthcare Managed Medicare	$945.18

SHORT LESSER METZ-PLATE

Facility

$1,602.00

Service Code	HCPCS C1713
Hospital Charge Code	8807701
Hospital Revenue Code	278
Min. Negotiated Rate	$1,121.40
Max. Negotiated Rate	$1,441.80
Rate for Payer: Aetna of IA Commercial	$1,441.80
Rate for Payer: Aetna of IA Medical Rental Products	$1,441.80
Rate for Payer: Cash Price	$1,281.60
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$1,201.50
Rate for Payer: Medical Associates Commercial	$1,201.50
Rate for Payer: Midlands Choice Commercial	$1,121.40
Rate for Payer: United Healthcare Commercial	$1,441.80

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH CC

Facility

$22,931.65

Service Code	MSDRG 511
Min. Negotiated Rate	$22,599.29
Max. Negotiated Rate	$22,931.65
Rate for Payer: Amerigroup Medicaid	$22,820.86
Rate for Payer: Iowa Total Care Managed Medicaid	$22,599.29
Rate for Payer: Molina Healthcare Managed Medicaid	$22,931.65

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITH MCC

Facility

$25,942.51

Service Code	MSDRG 510
Min. Negotiated Rate	$25,566.52
Max. Negotiated Rate	$25,942.51
Rate for Payer: Amerigroup Medicaid	$25,817.17
Rate for Payer: Iowa Total Care Managed Medicaid	$25,566.52
Rate for Payer: Molina Healthcare Managed Medicaid	$25,942.51

SHOULDER, ELBOW OR FOREARM PROCEDURES, EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC

Facility

$11,414.03

Service Code	MSDRG 512
Min. Negotiated Rate	$11,248.60
Max. Negotiated Rate	$11,414.03
Rate for Payer: Amerigroup Medicaid	$11,358.88
Rate for Payer: Iowa Total Care Managed Medicaid	$11,248.60
Rate for Payer: Molina Healthcare Managed Medicaid	$11,414.03

SIGMOIDOSCOPY, FLEXIBLE; WITH BIOPSY, SINGLE OR MULTIPLE

Facility

$2,844.40

Service Code	CPT 45331
Hospital Revenue Code	750
Min. Negotiated Rate	$2,582.18
Max. Negotiated Rate	$2,844.40
Rate for Payer: Wellmark IA HMO WHPI	$2,582.18
Rate for Payer: Wellmark IA PPO	$2,844.40

SIGMOIDOSCOPY W TATTOOING

Professional

Both

$1,025.00

Service Code	CPT 45335
Hospital Charge Code	8825541
Hospital Revenue Code	975
Min. Negotiated Rate	$248.80
Max. Negotiated Rate	$768.75
Rate for Payer: Amerigroup Medicaid	$251.24
Rate for Payer: Cash Price	$820.00
Rate for Payer: Cash Price	$820.00
Rate for Payer: Iowa Total Care Managed Medicaid	$248.80
Rate for Payer: Medical Associates Commercial	$768.75
Rate for Payer: Midlands Choice Commercial	$717.50
Rate for Payer: Molina Healthcare Managed Medicaid	$250.02
Rate for Payer: Partners Health Alliance Commercial	$768.75
Rate for Payer: United Healthcare Commercial	$398.94
Rate for Payer: Wellmark IA HMO WHPI	$558.20
Rate for Payer: Wellmark IA PPO	$656.70

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC

Facility

$10,495.23

Service Code	MSDRG 555
Min. Negotiated Rate	$10,343.12
Max. Negotiated Rate	$10,495.23
Rate for Payer: Amerigroup Medicaid	$10,444.53
Rate for Payer: Iowa Total Care Managed Medicaid	$10,343.12
Rate for Payer: Molina Healthcare Managed Medicaid	$10,495.23

SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC

Facility

$5,602.86

Service Code	MSDRG 556
Min. Negotiated Rate	$5,521.66
Max. Negotiated Rate	$5,602.86
Rate for Payer: Amerigroup Medicaid	$5,575.79
Rate for Payer: Iowa Total Care Managed Medicaid	$5,521.66
Rate for Payer: Molina Healthcare Managed Medicaid	$5,602.86

SIGNS AND SYMPTOMS WITH MCC

Facility

$12,814.74

Service Code	MSDRG 947
Min. Negotiated Rate	$12,629.02
Max. Negotiated Rate	$12,814.74
Rate for Payer: Amerigroup Medicaid	$12,752.83
Rate for Payer: Iowa Total Care Managed Medicaid	$12,629.02
Rate for Payer: Molina Healthcare Managed Medicaid	$12,814.74

SIGNS AND SYMPTOMS WITHOUT MCC

Facility

$7,328.98

Service Code	MSDRG 948
Min. Negotiated Rate	$7,222.76
Max. Negotiated Rate	$7,328.98
Rate for Payer: Amerigroup Medicaid	$7,293.58
Rate for Payer: Iowa Total Care Managed Medicaid	$7,222.76
Rate for Payer: Molina Healthcare Managed Medicaid	$7,328.98

SI JOINT INJECT W FLUOROSCOPY

Professional

Both

$413.00

Service Code	CPT 27096
Hospital Charge Code	8059059
Hospital Revenue Code	964
Min. Negotiated Rate	$245.76
Max. Negotiated Rate	$372.20
Rate for Payer: Amerigroup Medicaid	$372.20
Rate for Payer: Cash Price	$330.40
Rate for Payer: Cash Price	$330.40
Rate for Payer: Iowa Total Care Managed Medicaid	$368.59
Rate for Payer: Medical Associates Commercial	$309.75
Rate for Payer: Midlands Choice Commercial	$289.10
Rate for Payer: Molina Healthcare Managed Medicaid	$370.39
Rate for Payer: Partners Health Alliance Commercial	$309.75
Rate for Payer: United Healthcare Commercial	$245.76
Rate for Payer: Wellmark IA HMO WHPI	$310.10
Rate for Payer: Wellmark IA PPO	$364.80

SI JOINT INJ W FLUOROSCOPY

Professional

Both

$532.00

Service Code	CPT 27096
Hospital Charge Code	8015252
Hospital Revenue Code	975
Min. Negotiated Rate	$245.76
Max. Negotiated Rate	$399.00
Rate for Payer: Amerigroup Medicaid	$372.20
Rate for Payer: Cash Price	$425.60
Rate for Payer: Cash Price	$425.60
Rate for Payer: Iowa Total Care Managed Medicaid	$368.59
Rate for Payer: Medical Associates Commercial	$399.00
Rate for Payer: Midlands Choice Commercial	$372.40
Rate for Payer: Molina Healthcare Managed Medicaid	$370.39
Rate for Payer: Partners Health Alliance Commercial	$399.00
Rate for Payer: United Healthcare Commercial	$245.76
Rate for Payer: Wellmark IA HMO WHPI	$310.10
Rate for Payer: Wellmark IA PPO	$364.80

silver nitrate Top Stick [VDMC]

Facility

$10.33

Service Code	NDC 12870-0001-02
Hospital Charge Code	10420587
Hospital Revenue Code	259
Min. Negotiated Rate	$7.23
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna of IA Commercial	$9.29
Rate for Payer: Aetna of IA Medical Rental Products	$9.29
Rate for Payer: Cash Price	$8.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.75
Rate for Payer: Medical Associates Commercial	$7.75
Rate for Payer: Midlands Choice Commercial	$7.23
Rate for Payer: United Healthcare Commercial	$9.29

silver nitrate Top Stick [VDMC]

Facility

$10.33

Service Code	NDC 12870-0001-02
Hospital Charge Code	10420587
Hospital Revenue Code	259
Min. Negotiated Rate	$4.65
Max. Negotiated Rate	$9.29
Rate for Payer: Aetna of IA Commercial	$9.29
Rate for Payer: Aetna of IA Medical Rental Products	$9.29
Rate for Payer: Aetna of IA Medicare	$5.89
Rate for Payer: Amerigroup Medicaid	$5.96
Rate for Payer: Amerigroup Medicare	$4.69
Rate for Payer: Cash Price	$8.26
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$7.75
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$4.65
Rate for Payer: Iowa Total Care Managed Medicaid	$5.90
Rate for Payer: Medical Associates Commercial	$7.75
Rate for Payer: Medical Associates Managed Medicare	$4.65
Rate for Payer: Midlands Choice Commercial	$7.23
Rate for Payer: Molina Healthcare Managed Medicaid	$5.99
Rate for Payer: Partners Health Alliance Commercial	$5.34
Rate for Payer: United Healthcare Commercial	$9.29
Rate for Payer: United Healthcare Managed Medicare	$6.09

silver sulfADIAZINE Top 1% Crm 400 gm [VDMC]

Facility

$209.76

Service Code	HCPCS A9270
Hospital Charge Code	10437891
Hospital Revenue Code	259
Min. Negotiated Rate	$94.39
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Aetna of IA Medicare	$119.56
Rate for Payer: Amerigroup Medicaid	$120.99
Rate for Payer: Amerigroup Medicare	$95.34
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$94.39
Rate for Payer: Iowa Total Care Managed Medicaid	$119.81
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Medical Associates Managed Medicare	$94.39
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: Molina Healthcare Managed Medicaid	$121.58
Rate for Payer: Partners Health Alliance Commercial	$108.55
Rate for Payer: United Healthcare Commercial	$188.78
Rate for Payer: United Healthcare Managed Medicare	$123.76

silver sulfADIAZINE Top 1% Crm 400 gm [VDMC]

Facility

$209.76

Service Code	HCPCS A9270
Hospital Charge Code	10437891
Hospital Revenue Code	259
Min. Negotiated Rate	$146.83
Max. Negotiated Rate	$188.78
Rate for Payer: Aetna of IA Commercial	$188.78
Rate for Payer: Aetna of IA Medical Rental Products	$188.78
Rate for Payer: Cash Price	$167.81
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$157.32
Rate for Payer: Medical Associates Commercial	$157.32
Rate for Payer: Midlands Choice Commercial	$146.83
Rate for Payer: United Healthcare Commercial	$188.78

silver sulfADIAZINE Top 1% Crm 50 gm [VDMC]

Facility

$53.08

Service Code	HCPCS A9270
Hospital Charge Code	10437826
Hospital Revenue Code	259
Min. Negotiated Rate	$37.16
Max. Negotiated Rate	$47.77
Rate for Payer: Aetna of IA Commercial	$47.77
Rate for Payer: Aetna of IA Medical Rental Products	$47.77
Rate for Payer: Cash Price	$42.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.81
Rate for Payer: Medical Associates Commercial	$39.81
Rate for Payer: Midlands Choice Commercial	$37.16
Rate for Payer: United Healthcare Commercial	$47.77

silver sulfADIAZINE Top 1% Crm 50 gm [VDMC]

Facility

$53.08

Service Code	HCPCS A9270
Hospital Charge Code	10437826
Hospital Revenue Code	259
Min. Negotiated Rate	$23.89
Max. Negotiated Rate	$47.77
Rate for Payer: Aetna of IA Commercial	$47.77
Rate for Payer: Aetna of IA Medical Rental Products	$47.77
Rate for Payer: Aetna of IA Medicare	$30.26
Rate for Payer: Amerigroup Medicaid	$30.62
Rate for Payer: Amerigroup Medicare	$24.12
Rate for Payer: Cash Price	$42.46
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$39.81
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$23.89
Rate for Payer: Iowa Total Care Managed Medicaid	$30.32
Rate for Payer: Medical Associates Commercial	$39.81
Rate for Payer: Medical Associates Managed Medicare	$23.89
Rate for Payer: Midlands Choice Commercial	$37.16
Rate for Payer: Molina Healthcare Managed Medicaid	$30.77
Rate for Payer: Partners Health Alliance Commercial	$27.47
Rate for Payer: United Healthcare Commercial	$47.77
Rate for Payer: United Healthcare Managed Medicare	$31.32

silver sulfADIAZINE topical 1% Crm 25 gm [VDMC]

Facility

$26.84

Service Code	HCPCS A9270
Hospital Charge Code	27608899
Hospital Revenue Code	259
Min. Negotiated Rate	$12.08
Max. Negotiated Rate	$24.16
Rate for Payer: Aetna of IA Commercial	$24.16
Rate for Payer: Aetna of IA Medical Rental Products	$24.16
Rate for Payer: Aetna of IA Medicare	$15.30
Rate for Payer: Amerigroup Medicaid	$15.48
Rate for Payer: Amerigroup Medicare	$12.20
Rate for Payer: Cash Price	$21.47
Rate for Payer: Health Alliance-Midwest, Inc. of IA Commercial	$20.13
Rate for Payer: Humana of IA Commercial PPO (non PPOx)/Medicare Advantage HMO/Medicare Advantage PPO/PFFS	$12.08
Rate for Payer: Iowa Total Care Managed Medicaid	$15.33
Rate for Payer: Medical Associates Commercial	$20.13
Rate for Payer: Medical Associates Managed Medicare	$12.08
Rate for Payer: Midlands Choice Commercial	$18.79
Rate for Payer: Molina Healthcare Managed Medicaid	$15.56
Rate for Payer: Partners Health Alliance Commercial	$13.89
Rate for Payer: United Healthcare Commercial	$24.16
Rate for Payer: United Healthcare Managed Medicare	$15.84

Know your out-of-pocket cost for care.

All Charges